What is the overall deductible?

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1 : 2016 Kaiser CO Silver Coverage Period: Beginning on or after 01/01/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: All Coverage Tiers Plan Type: POS *The Kaiser Permanente Point-of-Service Plan is jointly underwritten by Kaiser Foundation Health Plan, Inc. (KFHP) and Kaiser Permanente Insurance Company (KPIC). The HMO portion is underwritten by KFHP and the PPO and the Out-of-Network portion is underwritten by KPIC, a subsidiary of KFHP. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling or TTY 711. Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in the out of pocket limit? Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn t cover? Plan provider: $750 Individual / $1,500 Family, Non-plan provider: $1,500 Individual / $3,000 Family. Does not apply to preventive care services and provider office visits with copayments. No Yes, Plan provider: $5,000 Individual / $10,000 Family, Non-plan provider $10,000 Individual / $20,000 Family. Premiums, balanced-billed charges and health care this plan doesn t cover. No Yes, see or call (TTY 711) for a list of plan providers. No Yes You must pay all the costs up to the deductible amount before this plan begins to pay for covered services you use. Check your policy or plan document to see when the deductible starts over (usually, but not always, January 1st). See the chart starting on page 2 for how much you pay for covered services after you meet the deductible. You don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan covers. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don t count toward the out-ofpocket limit. The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Questions: Call (TTY 711) or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call (TTY 711) to request a copy.page 1 of 8

2 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use plan providers by charging you lower deductibles, copayments and coinsurance amounts. Common Medical Event If you visit a health care provider s office or clinic If you have a test Services You May Need Your Cost If You Use a Plan Your Cost If You Use a Non-Plan Limitations & Exceptions Primary care visit to treat an injury or $30 per visit 50% coinsurance Not subject to the overall deductible. illness Specialist visit $50 per visit 50% coinsurance Not subject to the overall deductible. Other practitioner office visit Preventive care / screening / immunization Diagnostic test (xray, blood work) Imaging (CT/PET scans, MRIs) Spinal manipulations: $30 per visit; Acupuncture services: 30% coinsurance No charge X-ray: 30% coinsurance; Lab: No charge 50% coinsurance 50% coinsurance 50% coinsurance 30% coinsurance 50% coinsurance Plan : Spinal manipulations are not subject to the overall deductible. Other practitioners are defined as spinal manipulations and acupuncture services. Coverage is limited to 20 visits per year for spinal manipulations and unlimited per year for acupuncture services. Plan : Not subject to the overall deductible. Plan : Diagnostic lab services: not subject to the overall deductible except when provided in a freestanding facility or the outpatient department of a hospital; 30% coinsurance in a freestanding facility or the outpatient department of a hospital. Non-Plan provider: Non-Plan provider:50% penalty without pre-certification, Page 2 of 8

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at If you have outpatient surgery If you need immediate medical attention If you have a hospital stay Services You May Need Generic drugs Brand drugs Non-preferred drugs Specialty drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Your Cost If You Use a Plan $10 retail prescription; $25 mail order $40 retail prescription; $100 mail order $60 retail prescription; $150 mail order Applicable Generic, Brand or Non-preferred cost shares may apply Your Cost If You Use a Non-Plan 50% Coinsurance retail prescription 50% Coinsurance retail prescription 50% Coinsurance retail prescription 50% Coinsurance retail prescription 30% coinsurance ---none--- 30% coinsurance ---none--- Limitations & Exceptions Generic drugs: Federally mandated over the counter items are covered with a prescription when filled at a Kaiser Permanente pharmacy. Non-preferred drugs: Must be authorized through the non-preferred drug process. All categories: Subject to formulary guidelines. Non-Plan provider: infertility drugs not covered. One retail copayment for each 30 day supply, for up to a 90 day supply. Mail Order copayment is for up to a 90 day supply. Plan : No charge for women s preventive contraceptives, in accordance with formulary guidelines. Non-Plan provider:50% penalty without precertification, Non-Plan provider:50% penalty without precertification, Urgent care ---none--- Facility fee (e.g., Non-Plan provider: 50% penalty without precertification, hospital room) Physician/surgeon Non-Plan provider: 50% penalty without precertification, up to fee $500 Page 3 of 8

4 Common Medical Event Services You May Need Your Cost If You Use a Plan Your Cost If You Use a Non-Plan Limitations & Exceptions If you have mental health, behavioral health, or substance abuse needs If you are pregnant Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpatient services Prenatal and postnatal care Delivery and all inpatient services $30 per individual visit; group visits are 50% of the individual visit 50% Coinsurance $30 per individual visit; group visits are 50% of the individual visit 50% Coinsurance Plan : Not subject to the overall deductible. Non-Plan provider: 50% penalty without precertification, Plan : Not subject to the overall deductible. Non-Plan provider: 50% penalty without precertification, Cost shown is for the series of routine prenatal care and first postnatal visit. Non-routine visits are covered at applicable office visit charge. Non-Plan provider: 50% penalty without precertification, Page 4 of 8

5 Common Medical Event If you need help recovering or have other special health needs If your child needs dental or eye care Services You May Need Your Cost If You Use a Plan Your Cost If You Use a Non-Plan Limitations & Exceptions Home health care Coverage is limited to 120 visits per year. Outpatient coverage (combined rehabilitation and habilitation) is visits limited to 60 visits combined per year (autism spectrum disorders Rehabilitation Inpatient: 30% coinsurance 50% Coinsurance are not subject to the visit limit); Inpatient in a services Outpatient: 30% coinsurance multi-disciplinary facility limited to 60 days per condition per year. Non-Plan provider: 50% penalty without pre-certification, Outpatient coverage (combined rehabilitation and habilitation) is limited to 60 visits combined Habilitation services per year (autism spectrum disorders are not subject to the visit limit) Non-Plan provider: 50% penalty without pre-certification, up to $500 Skilled nursing care Coverage is limited to 120 days per year. Non-Plan provider: 50% penalty without precertification, Durable medical equipment Hospice service ---none--- Coverage is limited to items on our DME formulary. Prosthetic arms and legs not to exceed 20% coinsurance Non-Plan provider: 50% penalty without pre-certification, up to $500 Eye exam Not covered Not covered No coverage for refraction eye exam Glasses Not covered Not covered No coverage for glasses Dental check-up Not covered Not covered No coverage for dental check-up Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn t a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Long-term care Weight loss programs Dental care (Adult and child) Non-emergency care when traveling outside the U.S. Glasses Routine foot care (unless medically necessary) Page 5 of 8

6 Other Covered Services (This isn t a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Infertility treatment Spinal manipulations Bariatric surgery Private-duty nursing Hearing aids Routine eye care (Adult) Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at or TTY 711. You may also contact your state insurance department, the U.S. Department of Labor, Employee Benefits Security Administration at or or the U.S. Department of Health and Human Services at x61565 or Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: The plan at or TTY 711; Department of Labor's Employee Benefits Security Administration at EBSA (3272) or or the Colorado Division of Insurance, Consumer Affairs Section, at 1560 Broadway, Ste 850, Denver, CO or call: (in-state, toll-free: ), or insurance@dora.state.co.us. Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Language Access Services: SPANISH (Español): Para obtener asistencia en Español, llame al or TTY/TDD: 711. TAGALOG (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa or TTY/TDD: 711. CHINESE: 若有問題 : 請撥打 或 TTY/TDD: 711 NAVAJO (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' or TTY/TDD: 711. To see examples of how this plan might cover costs for a sample medical situation, see the next page. Page 6 of 8

7 About these Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays $4,720 Patient pays $2,820 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Deductibles $800 Copays $20 Coinsurance $1,800 Limits or exclusions $200 Total $2,820 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays $3,660 Patient pays $1,740 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Deductibles $800 Copays $700 Coinsurance $200 Limits or exclusions $40 Total $1,740 Total amounts above are based on single person enrollment. Page 7 of 8

8 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don t include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren t specific to a particular geographic area or health plan. The patient s condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and coinsurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn t covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor s advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can t use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you ll find the same Coverage Examples. When you compare plans, check the Patient Pays box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you ll pay in out-ofpocket costs, such as copayments, deductibles, and coinsurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call (TTY 711) or visit us at If you aren t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at or call (TTY 711) to request a copy. Page 8 of 8

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10 TYPE OF COVERAGE Colorado Supplement to the Summary of Benefits and Coverage Form Kaiser Foundation Health Plan of Colorado Name of Carrier 2016 Kaiser Colorado Silver Name of Plan Large Employer Group Policy Policy Type 1. Type of plan. Point of Service Plan (POS) 2. Out-of-network care covered? 1 3. Areas of Colorado where plan is available. Only for specified services; patient pays more for such out-of-network care Plan is available only in the following counties as determined by zip code and employer service area selection: 1. For Denver/Boulder service area: Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, Gilpin, Jefferson, Larimer, Park and Weld; 2. For Southern Colorado: Crowley, Custer, Douglas, El Paso, Elbert, Fremont, Huerfano, Las Animas, Lincoln, Otero, Park, Pueblo and Teller; 3. For Southern Colorado KP Select Plan: Douglas, El Paso, Elbert, Fremont, Lincoln, Park, Pueblo and Teller; 4. For Northern Colorado: Adams, Larimer, Morgan, and Weld; 5. For Mountain Colorado: Eagle, Summit* *Garfield, Grand and Routt: Pending Division of Insurance review and approval. SUPPLEMENTAL INFORMATION REGARDING BENEFITS Important Note: The contents of this form are subject to the provisions of the policy, which contains all terms, covenants and conditions of coverage. It provides additional information meant to supplement the Summary of Benefits of Coverage you have received for this plan. This plan may exclude coverage for certain treatments, diagnoses, or services not specifically noted. Consult the actual policy to determine the exact terms and conditions of coverage. Description What this means. 4. Deductible Period Calendar year Calendar year deductibles restart each January Annual Deductible Type Single Coverage / Non-single Coverage Single means the deductible amount you will have to pay for allowable covered expenses when you are the only individual covered by the plan. Non-single is the deductible amount that must be met by one or more family members before any covered expenses are paid. It may be an aggregated amount (e.g., $3,000 per family ) or specified as the number of individual deductibles that must be met (e.g., 3 deductibles per family ).

11 6. What cancer screenings are covered? Breast Cancer (clinical breast exam, mammogram, genetic testing for inherited susceptibility for breast cancer); Colon and Rectal Cancer (fecal occult blood test (FIT), flexible sigmoidoscopy, barium enema, colonoscopy); Cervical Cancer (pap test); Prostate Cancer (digital rectal exam, serum prostatic specific antigen (PSA) LIMITATIONS AND EXCLUSIONS 7. Period during which pre-existing conditions are not Not applicable; plan does not impose limitation periods for pre-existing conditions. covered for covered persons age 19 and older How does the policy define a pre-existing condition? Not applicable. Plan does not exclude coverage for pre-existing conditions. 9. Exclusionary Riders. Can an individual s specific, preexisting condition be entirely excluded from the No policy? USING THE PLAN IN-NETWORK OUT-OF-NETWORK 10. If the provider charges more for a covered service than the plan normally pays, does the enrollee have to pay the difference? 11. Does the plan have a binding arbitration clause? Yes LANGUAGE ACCESS SERVICES: No Yes, members are responsible for any amounts over usual, reasonable and customary charges when receiving Emergency Services and Non-Emergency, Non-Routine Care. SPANISH (Español): Para obtener asistencia en Español, llame al or TTY/TDD Colorado Springs: Denver/Boulder: Questions: Call (TTY ) or visit us at If you are not satisfied with the resolution of your complaint or grievance, contact: Colorado Division of Insurance Consumer Affairs Section 1560 Broadway, Suite 850, Denver, CO Call: (in-state, toll-free: ) insurance@dora.state.co.us Endnotes

12 1 Network refers to a specified group of physicians, hospitals, medical clinics and other health care providers that this plan may require you to use in order for you to get any coverage at all under the plan, or that the plan may encourage you to use because it may pay more of your bill if you use their network providers (i.e., go in-network) than if you don t (i.e., go out-of-network). 2 Waiver of pre-existing condition exclusions. State law requires carriers to waive some or all of the pre-existing condition exclusion period based on other coverage you recently may have had. Ask your carrier or plan sponsor (e.g., employer) for details.